The Nature of Suicide Threats

by Tony Salvatore, M.A.

The term “suicide threat” brings to mind an anguished “cry for help” by someone at imminent risk of suicide.  This may be the case and warrants immediate crisis intervention when it is.  However, there are suicide threats that are less a “cry for help” than an effort to bypass the established channels to get it.  This second form of suicide threat is usually devoid of any imminent risk.  Both variations are frequently encountered by emergency responders and behavioral health staff.

 

Basically, a suicide threat is a type of “suicide communication” and the common signal of potential suicide risk.  It is “any interpersonal action, verbal or nonverbal, without a direct self-injurious component, that a reasonable person might interpret as…communicating that suicidal behavior might occur in the near future” (Silverman et al., 2007).   Suicide threats may convey definite suicidal intent, involve no suicidal intent, or be unclear as to suicidal intent (Silverman et al., 2007).

 

A suicide threat may not always be a reflection of suicidal ideation involving any thought of death.  However, any suicide threat connotes the possibility of pending more active and possibly harmful suicidal behavior so it must be taken seriously.  At the very least this should involve screening the individual for signs of suicide risk, a specific suicide plan, and intent.  When these factors are present a voluntary or involuntary psychiatric evaluation may be in order.

 

A suicide threat grabs most people’s attention, particularly if those it is directed at care about the person voicing the threat or have some responsibility for her or his well-being.  This gives suicide threats the power to provoke a response whether or not suicidal intent is actually present.  Suicide threats get a gatekeeper’s full attention and can immediately open doors.  This feature has not been lost on substance abusers and others who wish to elude contact with the criminal justice system or expedite admission to an inpatient treatment setting.

 

While we must take a suicide threat at face value as a sign of potential suicide risk, it would be helpful to know when this is actually so.  It has been suggested that the nature of a threat may indicate if it is accompanied by intent.  Consider these two threats:

 

“I am going to kill myself tonight by [insert lethal means].”

“I will kill myself tonight if I have to go back to jail.”

 

The first is an unconditional statement of intent with a plan comprising a definite timeframe and means.  The second also gives a timeframe, but it is conditional and “sets the terms” under which “intent” may become effective.  The first is a “non-contingent suicide threat” which is passive and does not include any demands; the second is a “contingent suicide threat” which may be dramatic and predicated on secondary gain to the individual (Lambert, 2002).

 

Whereas emergency responders, crisis center and ER staff, and facility admissions personnel have probably heard both types of suicide threats, it is likely that they more often hear threats that are conditional in nature.  This is borne out by the research.  Those who make contingent suicide threats are more likely to have diagnoses of substance dependence and also to be at low risk of suicide (Lambert, 2002).  On the other hand, those making non-contingent threats are more likely to be characterized by severe depression rather than substance dependence, and also to be at high risk of suicide.

 

The nature of the suicide threat may give some indication of the nature of the suicidality and, correspondingly, the level of suicide risk that may be present.  Non-contingent threats tend to be associated with acute suicidality; contingent threats are more often linked to what has been called chronic suicidality.  It is hoped that further research may provide screening and assessment tools that can validly distinguish each type of suicide threat.

 

 

The Crisis Continuum

By Tony Salvatore, MA

Mental health consumers and providers, and often family members and others, often use the term “crisis” to encompass a wide range of personal, interpersonal, and environmental situations with current or anticipated negative consequences. This “one size fits all” concept of a crisis is overly simplistic, obscures or minimizes the complexity of the situation, and impedes effective intervention and resolution.

Mental illness-related crises vary in scale and in terms of how they affect the individual. They also seem to follow trajectories and may move to higher levels of risk. All may be triggered by life events (or an individual’s anticipation of an adverse life event) that produces emotional discomfort or even the recurrence of psychiatric symptoms. Continue reading

Do 90% of Suicide Victims Really Have Serious Mental Illness? (Part 1)

By Tony Salvatore, MA

Anyone who turns to the print or electronic sources for insight on the topic of suicide and mental illness will encounter this statement in some form: Ninety percent of suicide victims had a psychiatric disorder.(1)  The implication of this contention is almost causal in nature, and it has taken on the trappings of a veritable “truth” of suicide prevention that is rarely questioned.  Mental illness has been shown to be a factor in suicide, but “the relative importance of mental disorders compared to social strains is not fully clear.”(2)

Here we will look into the origins of this assertion and consider some issues with its underlying methodology.  In Part 2, we will look at some actual data on the incidence of mental illness in suicide victims, examine mental illness and suicide from the perspective of current theories of suicide, and show mental illness in its proper role as a suicide risk factor. Continue reading

Do 90% of Suicide Victims Really have Serious Mental Illness? (Part 2)

By Tony Salvatore, MA

In our previous blog, we looked at the use of the psychological autopsy method in suicide research and questioned this approach and its results.  Here we will consider some “hard” data on the incidence of psychiatric diagnoses in suicide victims at the time of death, look at how the role mental illness plays in two current theories of suicide, and argue that mental illness is a serious suicide risk factor but not necessarily the key independent variable in the onset of suicidality in at-risk persons.

Some Countervailing Data

The Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS), has collected data on suicide from death certificates and other sources from sixteen states.[1]  In 2008, of 9276 suicides, approximately 45.4% had a diagnosed mental illness at death.  The NVDRS has found that “mental health problems were the most common circumstances among suicide decedents” in the US.  However, the incidence in a very large population of victims is half that reported by psychological autopsy studies.  Continue reading